Practice Environment


​Physician Health & Wellness

​Practice Environment

The practice environment is the most commonly referenced contributor to burnout for physicians. Drivers such as autonomy, workload, organizational culture, efficiency, and resources can lead to burnout and exhaustion.  

Pediatricians often report frustration with these barriers to quality practice and patient engagementMore than half report being very or moderately stressed by administrative duties of practice such as documenting patient information in the EHR or catching up on work at home.  

"I feel the more we become employees and less physicians it gets harder. Many colleagues have simply gone part time instead of dealing with all of the work. I try to stay diversified--it works for me--I don't have my entire foot in one bucket but multiple buckets--giving me a variety in my practice as well as options in case one thing stops working for me or is causing me too much stress. If I was 100% clinical work I would have already quit but mix of clinical and non-clinical work has kept me in the game."  Pediatrician 


Equitable work environments and our wellness 


The pediatric workforce is becoming more diverse. However, inequities in the organizational culture and structure 
continue to contribute to increased stress and burnout. For example, female physicians report having less control over their day-to-day work, are compensated at a lower rate, experience more strain in the work-home balance, and are more likely to report burnout than their male colleagues (JAMA 2019) 

Microaggressions are nonverbal and verbal slights or snubs that are often the behavioral manifestations of unconscious bias.  Microaggressions occur daily.  They may appear harmless but they can accumulate over the course of a day, week or career impacting individuals’ engagement in the work environment as well as their wellness.   

Compassion fatigue- Role of the organization 


Compassion fatigue, also called vicarious or secondary trauma, 
results from giving high levels of energy and compassion over a prolonged period to those who are suffering, often without experiencing the positive outcomes of seeing patients improve. (McHolm, 2006) Symptoms may include sleep disturbances, intense emotional reactions, isolation, loss of morale, decrease in decision making. Compassion fatigue is different but related to burnout.  

Organizational and department leaders should support staff after traumatic or adverse patient eventsA practice or organization can: 

 

  • Offer respite space where staff can decompress after an adverse event or interaction 

  • Consider offering resources for depression screening, substance abuse, ect.

  • Provide team meetings and debriefing discussions regularly 

  • Train staff on compassion fatigue  

  • Train supervisors in reflective supervision, motiviational interviewing

  • Recruit staff who are trauma-aware and non-judgemental

 

Organizational strategies 


Changing organizational culture can be difficult but not impossible. Below is an offering of strategies and resources you can apply 
within your organization. While exploring these resources, also remember: 

 

  • Assess the ProblemWhat issue do we need to solve? 

  • Build a team- involve leadership: Who can help you create change? 

  • Determine areas of focus- What needs to be changes to increase professional satisfaction? 

  • EvaluateHow will we know it was successful? 

 

    Creating Flexible Work Environments

    Flexible work environments can support work-life integration for pediatricians. It can also be a recruiting strategy for organizations as well as a tool for providing patient care. Some flexible options might include: 

    • Float pools- use part- or full-time float teams to cover gaps in staffing, vacation, and leave time.  

    • Job-sharing 

    • Alternative scheduling: Allow pediatricians to design their own clinic and administrative hours. A 9 to 5 might not be the best fit for everyone or your patients.  

    • Telecommuting: This is often for office staff but can be offered as work-from-home administrative time for direct service providers.  

    Read more:  

    Workflex and Healthcare Guide, When Work Works 

    Reducing Administrative Burden

    Team based care 

    Team based care engages a greater number of staff in patient care and affords physicians, as the team lead, additional time with patients and their families. Team members should be aware of the health history, status, and unique needs of the patient and family, and are assigned different responsibilities, which together are designed to result in continuous, comprehensive, coordinated care during and between visits. As a result, all members of the team feel engaged in their key role of caring for the patient. 

    A successful collaborative team environment includes the following: 

    • A culture of trust 

    • Clearly defined roles and responsibilities 

    • Strong leadership 

    • Respectful and empathetic open communication 

    • Appreciation of diversity 

    • Equal participation among all team members 

    • Established goals 

    • Consensus decision making 

    • Solution focused problem solving 

    • Ongoing evaluation 

    Read more: 

    Creating Efficiency – Team Huddles 

    Key Elements of Highly Effective Teams, Council on Medical Students Education Pediatrics 2019

    Team Documentation 

    Team documentation or “scribing” is a process where team members assist with documenting visit notes, entering orders and referrals, and preparing prescriptions, during a patient visit. (AMA Steps Forward Team Documentation) Medical scribes have been shown to enhance clinical documentation, improve revenue collection, increase physician satisfaction, and reduce burnout. (JAMA 2015; J Am Board Fam Med 2015)

    Read more:

    Team Documentation: Improve Efficiency, Workflow, and Patient Care, AMA Steps Forward (CME bearing module) 

    Assess the physical practice environment

    The physical practice environment can also influence physician dissatisfaction. Challenging work environments such as a lack of meeting space, equipment, room availability, etc. can contribute to frustration and ultimately burnout. Assessing the barriers within the physical practice environment may offer opportunities to build a success in creating wellness strategies or organizational changes. Some common changes to the physical environment might include: 

    • Select furniture that enables eye to eye contact with families.  

    • Organize patient rooms that promote communication 

    • Offer a well-designed family or waiting area 

    • Create public spaces that encourage team interaction and communication such as open workstations 

    • Offer sources of natural light and/or images of nature 

    • Space for scribes or other team members to help with EMR input 

    • A respite or wellness room for staff to rest or recover after stressful encounters.  

    • Access to healthy foods and drinks in meeting or lounge spaces 

    Lengthen visit time if possible 

    The number of recommendations and tasks pediatricians are expected to complete during a well-child visit continues to grow. Lengthening the time a pediatrician can spend with each family is a possible strategy for reducing the administrative burden. This extra time can be offered as family discussion or supplemental administrative time to complete prescriptions, documentation, or anticipatory guidance.   

    Read more:

    Patients Over Paperwork, Centers for Medicare and Medicaid Service

    Health Information Technology

    Pediatricians reported spending a mean time of 3.4 hours per day on clinical documentation on a typical day (Journal of Pediatrics 2019

    The electronic health record (EHR) is a common source of inefficiency and contributor to burnout. On average, pediatricians spend 3 hours on clerical work per day. (Journal of Pediatrics 2019) There are several ways practices can reduce their time in the EHR, in addition to the strategies for reducing administrative burden listed above. Initially, organizations should appoint a practicing physician to the organization decision making bodies with the task informing how to streamline and reduce clerical work. This decision making body can focus on the following questions: 

    • Must this process be performed? 

    • If so, can it be made more efficient? (Does it need this many “clicks”?) 

    • Can it be executed by other staff?
      *Adapted from An Organizational Framework to Reduce Professional Burnout and Bring Back Joy in Practice The Joint Commission 2017 

    Invest in training 

    EHR training can decrease time spent documenting patient visits and increase physician satisfaction. Individually tailored EHR training has been shown to improve physician confidence and efficiency. (J Oncology Practice 2018

    One on one or small group trainings can offer physicians time to practice utilizing and exploring the EHR. This can also create opportunities for identifying redundancies and opportunities for customization- both important tools against excess physician clerical time.  

    In addition to continued training and technical support, consider building small staff workgroups to identify inefficiencies within your EHR. Make sure this team meets regularly (at first weekly then monthly) and receives training and technical support often.  

    Read more: 

    One-on-one EHR training improved physician satisfaction, saves time, Modern Healthcare 2018 

    Pediatric Functionality  

    Pediatricians and other clinicians who care for children have specific needs for health information technology tools. The 2016 Electronic Health Records Periodic Survey found that features most likely missing from EHRs of office based pediatricians were those related to pediatric functionality such as reminders for interventions, tests for preventive care, adherence to well-child visits, and calculation of catch-up immunizations (Journal of Pediatrics 2019

    The AAP Child Health Informatics Center identified eight priorities essential to increasing the functionality of HIT tools for pediatric providers.  

    • Use biometric-specific norms for growth curves and support growth charts for children. 

    • Ability to document all guardians and caregivers 

    • Segments access to information 

    • Synchronize immunization histories with registries 

    • Age-and weight specific single dose-range checking 

    • Transferrable access authority 

    • Associate mother’s demographics with newborn 

    • Identify incomplete preventive care opportunities 

    Read more: 

    EHR's Contributing to Physician Burnout: What You Can Do to Reduce Frustration

    Electronic Health Records for Pediatricians: A Shopper’s Guide 

    Children’s Electronic Health Format, Agency for Healthcare Research and Quality 

    Leadership and Professional Satisfaction

    Organizational leadership and professional satisfaction have both been linked to prevention of burnout and increased provider engagement. Physicians who spend at least 20% of their professional time on work they find most meaningful are at a dramatically lower risk for burnout. (Mayo Clinic Proc. 2017) 

    “Leaders play a critical role in the professional satisfaction, well-being, and productivity of the individuals whom they lead.” – Tait Shanafelt MD. 

    Effective leaders have been shown to create greater staff satisfaction and prevent burnout. These leaders tend to have similar characteristics: 




    Organizational strategies for building better leaders and increasing professional satisfaction: 
    • Choose and evaluate leaders based on skills related to engagement, mentorship, partnerships, and communication.  

    • Support leadership development for all providers including part time staff. 

    • Create leadership opportunities or eliminate barriers for promotion for part time staff such as stopping the tenure track during family leave or creating flexible hours for leadership positions. 

    • Designate FTE for professional passion or development interests.  

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Additional Resources

AAP Practice Transformation

Patients Over Paperwork
Centers for Medicare and Medicaid Services

Periodic Survey #98 Physician Health and Wellness

Gender Differences in Pediatricians' Work-Life Balance Attitudes and Satisfaction: Results from the Periodic Survey